Safety and efficacy of surgical management of hyperthyroidism: 15-year experience from a tertiary care center in a developing country

2021 Asia-Pacific Graves' Disease Consortium Survey of Clinical Practice Patterns in the Management of Graves' Disease

AIM

Although Graves' disease (GD) is common in endocrine practices worldwide, global differences in diagnosis and management remain. We sought to assess the current practices for GD in countries across Asia and the Pacific (APAC), and to compare these with previously published surveys from North America and Europe.

METHODS

A web-based survey on GD management was conducted on practicing clinicians. Responses from 542 clinicians were received and subsequently analysed and compared to outcomes from similar surveys from other regions.

RESULTS

A total of 542 respondents participated in the survey, 515 (95%) of whom completed all sections. Of these, 86% were medical specialists, 11% surgeons, and 3% nuclear medicine physicians. In addition to serum thyroid-stimulating hormone (TSH) and free thyroxine assays, most respondents would request TSH-receptor autoantibody (TRAb) measurement (68%) during initial work-up. Thyroid ultrasound is requested by about half of respondents (53%), while the use of nuclear medicine scans is limited. The preferred first-line treatment is anti-thyroid drug (ATD) therapy (79%) with methimazole (MMI) or carbimazole (CBZ), followed by radioiodine (RAI; 19%) and surgery (2%). In case of surgery, one-third of respondents would opt for a subtotal rather than a total thyroidectomy. In case of mild Graves orbitopathy (GO), ATDs (67%) remains the preferred treatment, but a larger proportion of clinicians prefer surgery (20%). For a patient with intention to conceive, the preferred treatment pattern remained unchanged, although propylthiouracil (PTU) became the preferred ATD-agent during the first trimester. In comparison to European and American practices, marked differences were noted in the relatively infrequent usage of nuclear medicine scans and the overall higher use of a ATDs and β-blockers and adjunctive ATD-treatment during RAI in the APAC-group.

CONCLUSION

Although regional differences regarding the diagnosis and management of GD are apparent in this first pan-Asia-Pacific survey, this study reveals the overall approach to the management of this disease in Asia-Pacific generally tends to fall between the trends appreciated in the American and European cohorts.

Diagnosis and Management of Graves' Disease in Thailand: A Survey of Current Practice

BACKGROUND

The data on clinical practice patterns in the evaluation and management of Graves' disease (GD) are limited in Asia. The aims of this survey were to report the current practices in the management of GD in Thailand and to examine any international differences in the management of GD.

METHODS

Members of the Endocrine Society of Thailand who were board certified in endocrinology (N = 392) were invited to participate in an electronic survey on the management of GD using the same index case and questionnaire as in previous North American and European surveys.

RESULTS

One hundred and twenty responses (30.6%) from members were included. TSH receptor antibody measurement (29.2%), thyroid ultrasound (6.7%), and isotopic studies (5.9%) were used less frequently to confirm the etiology compared with those in North American and European surveys. Treatment with an antithyroid drug (ATD) was the preferred first choice of therapy (90.8%). Methimazole at 10-15 mg/day with a beta-blocker was the initial treatment of choice. The preferred ATD in pregnancy was propylthiouracil in the first trimester and methimazole in the second and third trimesters, which was similar to the North American and European surveys.

CONCLUSION

Ultrasound and isotopic studies will be requested only by a small proportion of Thai endocrinologists. Higher physician preference for ATD is similar to Europe, Latin America, and other Asian countries. Geographical differences in the use of ATD, radioactive iodine, and thyroidectomy exist.

A Study on Nonthermal Irreversible Electroporation of the Thyroid

Background:

Nonthermal irreversible electroporation is a minimally invasive surgery technology that employs high and brief electric fields to ablate undesirable tissues. Nonthermal irreversible electroporation can ablate only cells while preserving intact functional properties of the extracellular structures. Therefore, nonthermal irreversible electroporation can be used to ablate tissues safely near large blood vessels, the esophagus, or nerves. This suggests that it could be used for thyroid ablation abutting the esophagus. This study examines the feasibility of using nonthermal irreversible electroporation for thyroid ablation.

Methods:

Rats were used to evaluate the effects of nonthermal irreversible electroporation on the thyroid. The procedure entails the delivery of high electric field pulses (1-3 kV/cm, 100 microseconds) between 2 surface electrodes bracing the thyroid. The right lobe was treated with various nonthermal irreversible electroporation pulse sequences, and the left was the control. After 24 hours of the nonthermal irreversible electroporation treatment, the thyroid was examined with hemotoxylin and eosin histological analysis. Mathematical models of electric fields and the Joule heating-induced temperature raise in the thyroid were developed to examine the experimental results.

Results:

Treatment with nonthermal irreversible electroporation leads to follicular cells damage, associated with cell swelling, inflammatory cell infiltration, and cell ablation. Nonthermal irreversible electroporation spares the trachea structure. Unusually high electric fields, for these types of tissue, 3000 V/cm, are needed for thyroid ablation. The mathematical model suggests that this may be related to the heterogeneous structure of the thyroid-induced distortion of local electric fields. Moreover, most of the tissue does not experience thermal damage inducing temperature elevation. However, the heterogeneous structure of the thyroid may cause local hot spots with the potential for local thermal damage.

Conclusion:

Nonthermal irreversible electroporation with 3000 V/cm can be used for thyroid ablation. Possible applications are treatment of hyperthyroidism and thyroid cancer. The highly heterogeneous structure of the thyroid distorts the electric fields and temperature distribution in the thyroid must be considered when designing treatment protocols for this tissue type.

A Practical Mathematic Method to Predict and Manage Hypocalcemia After Parathyroidectomy and Thyroidectomy

OBJECTIVE

Prediction and early intervention for hypocalcemia following parathyroidectomy and total thyroidectomy can decrease hospital cost and prevent severe hypocalcemia-related complications. This study aims to predict the severity of hypocalcemia after parathyroidectomy or thyroidectomy and to stratify patients into groups with different levels of risk for developing severe hypocalcemia, so that higher risk patients may be monitored more closely and receive earlier interventions.

METHODS

This was a retrospective cohort study of 100 patients with primary hyperparathyroidism who underwent parathyroidectomy as the primary treatment modality at a tertiary care hospital. Clinical information, including demographic information, perioperative PTH and calcium levels, vitamin D levels, weight of the pathologic glands removed, gland pathology, and re-admission rates, were retrieved. Statistical analysis was performed to analyze the association between collected variables and percentage of calcium drop following parathyroidectomy with statistical significant set at P-values <0.05.

RESULTS

Age, sex, and vitamin D level provided very minimal information to quantify risks of postoperative hypocalcemia. The percentage of decrease from preoperative PTH level to the lowest PTH level after the removal of the abnormal gland(s) is the most significant predicting factor for the severity of postoperative hypocalcemia. There is a mathematic regressional correlation between them. A formula was generated to quantify this linear relationship between them, and the nadir calcium can be calculated as Canadir=Capreop*[1-0.35*(PTHpreop-PTHintraop)2PTHpreop2], where Ca_nadir = the lowest postoperative calcium level, and PTH_intraop = PTH level 15 minutes after removal of the abnormal gland, with the value of R² > 0.7. The formula has been tested primarily in our patient population with good reliability.

CONCLUSIONS

The highest preoperative, lowest postoperative, and change in PTH level can help us reliably calculate the trend of postoperative calcium level. Decision to pursue early interventions can be made based on the calculated result from the formula we obtained.

Role of pre-operative vitamin D supplementation to reduce post-thyroidectomy hypocalcemia; Cohort study

INTRODUCTION

Hypocalcaemia after thyroidectomy is observed with increasing frequency, often resulting in prolonged hospital stay with increased use of resources, delayed return to work and reduced quality of life. The administration of vitamin D is essential in the therapy of postoperative hypocalcaemia. What has not been examined so far is whether and how routine preoperative vitamin D prophylaxis can help to prevent postoperative hypocalcaemia.

MATERIALS AND METHODS

This is a prospective cohort study which was conducted from June 2016 to July 2017 at a tertiary care hospital. One hundred and two patients with thyroid disease who were admitted for thyroid surgery were interviewed and underwent physical examination and laboratory investigations. The patients enrolled in the study were randomly assigned to either the Interventional group (Pre-operative Vitamin D Supplementation) or the control group (placebo). The work is reported in line with the standards set by STROCCS criteria [1].

RESULTS

Out of 102 patients there were 89 females (87.25%) and 13 males (12.7%) with a mean age of 39.35 ± 7.01 years. In the test group 45 (88.2%) patients had no clinical hypocalcemia, 5 (9.82%) had latent while 1 (2%) patient had overt hypocalcemic symptoms. In placebo group 37 (72.5%) had no clinical hypocalcemia, 10 (19.6%) had latent and 4 (7.8%) had overt hypocalcemic symptoms. (P-value<0.05).

CONCLUSION

As the general population is deficient in Vitamin D, a prophylactic vitamin D dose given in immediate preoperative period can significantly reduce acute symptomatic postoperative hypocalcemia in patients undergoing thyroid surgery.

Incidental thyroid carcinoma in surgery-treated hyperthyroid patients with Graves' disease: a systematic review and meta-analysis of cohort studies

Background

The association between Graves’ disease (GD) and thyroid carcinoma remains controversial. This study aimed to investigate incidental thyroid carcinoma (ITC) in surgery-treated hyperthyroid patients with and without GD.

Materials and methods

We searched PubMed and EMBASE for cohort studies investigating ITC in surgery-treated hyperthyroid patients without prediagnosed thyroid carcinoma in accordance with the Meta-Analysis of Observational Studies in Epidemiology guidelines. The last search was updated to January 23, 2018. All statistical tests were performed using Review Manager 5.3 and STATA version 12.0.

Results

Eleven cohort studies involving 10,743 GD and 3,336 non-GD patients were included. The pooled prevalence of ITC was 7.0% (95% confidence interval [CI] 4.5–9.6), and was comparable in surgery-treated GD and non-GD hyperthyroid patients (GD vs non-GD: pooled odds ratio [OR], 1.0; 95% CI: 0.68–1.46; P=0.98). In the subgroup analysis, toxic adenoma and toxic nodular goiter showed no difference when comparing with GD (pooled OR, 0.53; 95% CI: 0.21–1.36; P=0.18 and pooled OR, 1.01; 95% CI: 0.65–1.57; P=0.95, respectively).

Conclusion

Our study demonstrated that GD was not associated with increased risk of ITC in surgery-treated hyperthyroid patients.

The Impact of Uniform Capsular Dissection Technique of Total Thyroidectomy on Postoperative Complications: An Experience of More Than 1000 Total Thyroidectomies from an Endocrine Surgery Training Centre in North India

BACKGROUND

Total thyroidectomy (TT) with a uniform technique of capsular dissection (CD) is the preferred technique worldwide. The aim of study is to analyze the impact of uniform technique of CD for done as primary surgery at an endocrine surgery training centre.

PATIENTS AND METHODS

Retrospective review from 1995 to 2009. Data collected from hospital records and follow-up.

RESULTS

One thousand and thirty-eight cases were included, with mean age 42.91 ± 13.48 years; male:female - 1:2.2; mean duration of goiter - 99.83 ± 105.1 months; 67.8% were euthyroid and 30.7% - hyperthyroid at initial presentation; 35.5% were malignant. Surgery includes TT alone - 77.7% and TT with lymph nodes dissection - 22.3%; sternotomy required in 1.2% and thoracotomy in 0.1%; tracheomalacia present in 3.9%; however, tracheostomy required in 4.5% and parathyroid autotransplantation in 21%; Peroperative mean gross gland weight was 124.34 ± 129.85 g. Complications include hypocalcemia (temporary - 35.9%; permanent - 1.3%); recurrent laryngeal nerve palsy (temporary - 2.7%; permanent - 91%); hemorrhage - 1.3%; and various others.

CONCLUSION

TT with uniform technique of CD is a safe procedure. Certain risk factors may predispose to complications, which can be avoided and managed adequately if anticipated beforehand.

Access, availability, and infrastructure deficiency: The current management of thyroid disease in the developing world

Thyroid disease, a neglected tropical disease and the most common noncommunicable disease in the developing world, is overlooked, under-diagnosed, and inadequately managed. The spectrum of thyroid disorders in the developing world is qualitatively different from that found in industrialized countries. This qualitative difference has resulted in limited access to clinical, laboratory, and imaging resources that are necessary for the care of patients with thyroid disease. The management of thyroid disease in the developing world is comparable to the care provided for disorders of the thyroid in North America fifty years ago.This article reviews public health and clinical aspects of developing world medical and surgical thyroid disease. Topics covered include iodine deficiency disorders, congenital hypothyroidism, goiter, thyroid cancer, and hyper- and hypothyroidism. The review concludes with a description of programs based on smartphone technology to improve the availability, affordability, and quality of thyroid disease care.

Hyperthyroidism

Hyperthyroidism is characterised by increased thyroid hormone synthesis and secretion from the thyroid gland, whereas thyrotoxicosis refers to the clinical syndrome of excess circulating thyroid hormones, irrespective of the source. The most common cause of hyperthyroidism is Graves' disease, followed by toxic nodular goitre. Other important causes of thyrotoxicosis include thyroiditis, iodine-induced and drug-induced thyroid dysfunction, and factitious ingestion of excess thyroid hormones. Treatment options for Graves' disease include antithyroid drugs, radioactive iodine therapy, and surgery, whereas antithyroid drugs are not generally used long term in toxic nodular goitre, because of the high relapse rate of thyrotoxicosis after discontinuation. β blockers are used in symptomatic thyrotoxicosis, and might be the only treatment needed for thyrotoxicosis not caused by excessive production and release of the thyroid hormones. Thyroid storm and hyperthyroidism in pregnancy and during the post-partum period are special circumstances that need careful assessment and treatment.

Safety and Effectiveness of Total Thyroidectomy and Its Comparison with Subtotal Thyroidectomy and Other Thyroid Surgeries: A Systematic Review

Diseases associated with the thyroid gland are one of the most frequently seen endocrine disorders across the globe. Total thyroidectomy is currently the preferred treatment for many thyroid diseases. Controversies exist among surgeons regarding safety of total thyroidectomy due to the risk associated with it like postoperative hypoparathyroidism or recurrent laryngeal nerve damage. Since, in the recent years, the incidence of thyroidectomy is in increasing trend in south Indian population, this review aims to study the available data regarding the appropriateness and safety of total thyroidectomy and compares it with subtotal thyroidectomy and other thyroid surgeries. This is a retrospective comprehensive review of various articles and publications regarding total and partial thyroidectomy performed across the world. Many retrospective studies and few prospective studies suggest that the incidence of transient hypocalcemia is higher after total thyroidectomy than after subtotal thyroidectomy, but the incidence of other complications including recurrent laryngeal nerve palsy and postoperative hematoma is not significantly different between the two procedures. Hence in our review we found that total thyroidectomy is safe and cost effective with low complication rates and provides little significant advantage of being safer procedure compared to subtotal thyroidectomy.

Diagnosis and management of Graves disease: a global overview

Graves disease is an autoimmune disorder characterized by goitre, hyperthyroidism and, in 25% of patients, Graves ophthalmopathy. The hyperthyroidism is caused by thyroid hypertrophy and stimulation of function, resulting from interaction of anti-TSH-receptor antibodies (TRAb) with the TSH receptor on thyroid follicular cells. Measurements of serum levels of TRAb and thyroid ultrasonography represent the most important diagnostic tests for Graves disease. Management of the condition currently relies on antithyroid drugs, which mainly inhibit thyroid hormone synthesis, or ablative treatments ((131)I-radiotherapy or thyroidectomy) that remove or decrease thyroid tissue. None of these treatments targets the disease process, and patients with treated Graves disease consequently experience either a high rate of recurrence, if receiving antithyroid drugs, or lifelong hypothyroidism, after ablative therapy. Geographical differences in the use of these therapies exist, partially owing to the availability of skilled thyroid surgeons and suitable nuclear medicine units. Novel agents that might act on the disease process are currently under evaluation in preclinical or clinical studies, but evidence of their efficacy and safety is lacking.

Feasibility and safety of minimal-incision thyroidectomy for Graves' disease: a prospective, single-center study

BACKGROUND

The role of minimally invasive surgery in Graves' disease is still controversial. The aim of this study was to compare the clinical outcomes of patients undergoing minimal-incision thyroidectomy with those undergoing conventional thyroidectomy for Graves' disease.

METHODS

A prospective study was performed on 148 patients undergoing total thyroidectomy. Seventy-one patients underwent minimal-incision thyroidectomy and 77 underwent conventional thyroidectomy. Minimal-incision thyroidectomy was proposed if the thyroid volume was ≤ 50 mL.

RESULTS

There were no significant differences in the operative time between minimal-incision thyroidectomy and conventional thyroidectomy. The length of skin incision was significantly shorter in the minimal-incision thyroidectomy than that in the conventional thyroidectomy group. The incidence of postoperative complications was similar in the 2 groups. Patients undergoing minimal-incision thyroidectomy experienced significantly less postoperative pain and were more satisfied with the cosmetic result than patients who underwent conventional thyroidectomy.

CONCLUSIONS

Minimal-incision thyroidectomy is a feasible and safe option for the surgical treatment of selected patients with Graves' disease.

Predictors of hypocalcemia after thyroidectomy: results from the nationwide inpatient sample

Hypocalcemia is a common complication following thyroidectomy. However, the incidence of postoperative hypocalcemia varies widely in the literature, and factors associated with hypocalcemia after thyroid surgery are not well established. We aimed to identify incidence trends and independent risk factors of postoperative hypocalcemia using the nationwide inpatient sample (NIS) database from 1998 to 2008. Overall, 6,605 (5.5%) of 119,567 patients who underwent thyroidectomy developed hypocalcemia. Total thyroidectomy resulted in a significantly higher increased incidence (9.0%) of hypocalcemia when compared with unilateral thyroid lobectomy (1.9%; P < .001). Thyroidectomy with bilateral neck dissection, the strongest independent risk factor of postoperative hypocalcemia (odds ratio, 9.42; P < .001), resulted in an incidence of 23.4%. Patients aged 45 years to 84 years were less likely to have postoperative hypocalcemia compared with their younger and older counterparts (P < .001). Hispanic (P = .003) and Asian (P = .027) patients were more likely, and black patients were less likely (P = .003) than white patients to develop hypocalcemia. Additional factors independently associated with postoperative hypocalcemia included female gender, nonteaching hospitals, and malignant neoplasms of thyroid gland. Hypocalcemia following thyroidectomy resulted in 1.47 days of extended hospital stay (3.33 versus 1.85 days P < .001).

Pattern and risk factors of central compartment lymph node metastasis in papillary thyroid cancer: a prospective study from an endocrine surgery centre

Lymphatic metastasis in papillary thyroid cancer (PTC) is eminent; however, the extent of central compartment lymph nodes dissection (CCD) is controversial and requires the knowledge of pattern and risk factors for central compartment lymph nodes metastasis (CCM). We did a prospective study of 47 cases with PTC who underwent total thyroidectomy (TT) with CCD with/without lateral lymph nodes dissection (LND). Clinicopathological profile including CCM as ipsilateral and contralateral was documented. On histopathology, the mean tumour size was 3.57 ± 2.42 cm 59.6% had CCM, which was bilateral in the majority (60.72%). The tumour-size was the most important predictor for lymph nodes metastasis-(P=0.018) whereas multicentricity-(P=0.002) and ipsilateral CCM-(P=0.001) were the predictors for contralateral CCM. The long-term morbidity of CCD done in primary setting is comparable with TT-alone. Bilateral CCD should be done with thyroidectomy in PTC, otherwise the risk of residual diseases and subsequent recurrence is high. The long-term morbidity is comparable in experienced hands.

Management of hyperfunctioning single thyroid nodules in the era of minimally invasive thyroid surgery

Both surgical excision and radioiodine ablation are effective modalities in the management of hyperfunctioning thyroid nodules. Minimally invasive thyroid surgery (MITS) using the lateral mini-incision approach has previously been demonstrated to be a safe and effective technique for thyroid lobectomy. As such MITS may offer advantages as a surgical approach to hyperfunctioning thyroid nodules without the need for a long cervical incision or extensive dissection associated with formal open hemithyroidectomy. The aim of the present study was to assess the safety and efficacy of MITS for the treatment of hyperfunctioning thyroid nodules. This is a retrospective case study. Data were obtained from the University of Sydney Endocrine Surgical Unit Database from 2002 to 2007. There were 86 cases of hyperfunctioning thyroid nodules surgically removed during the study period, of which 10 (12%) were managed using the MITS approach. The ipsilateral recurrent laryngeal nerve was identified and preserved in all cases with no incidence of temporary or permanent nerve palsy. The external branch of the superior laryngeal nerve was visualized and preserved in eight cases (80%). There were no cases of postoperative bleeding. There was one clinically significant follicular thyroid carcinoma in the series (10%). In nine of 10 cases (90%) normalization of thyroid function followed surgery. MITS is a safe and effective procedure, achieving the benefits of a minimally invasive procedure with minimal morbidity. As such it now presents an attractive alternative to radioiodine ablation for the management of small hyperfunctioning thyroid nodules.

Endoscopic subtotal thyroidectomy: the procedure of choice for Graves' disease?

BACKGROUND

The aim of this study was to evaluate the feasibility and outcomes of endoscopic subtotal thyroidectomy for Graves' disease.

METHODS

From August 1998 to April 2008, a total of 100 patients with benign thyroid diseases underwent endoscopic thyroidectomy via the breast approach. Among these patients, 42 underwent subtotal thyroidectomy for Graves' disease.

RESULTS

The resection was successfully completed endoscopically in 41 patients (98%). Overall, the mean operating time, mean blood loss, and mean resected thyroid weight were 277 minutes, 76 ml, and 49.9 g, respectively. As the resected thyroid weight increased, the operating time was significantly prolonged and the blood loss significantly increased. Morbidities included one permanent and one temporary case of recurrent laryngeal nerve palsy with hypocalcemia. A hypertrophic scar was seen in the right breast medial margin in three men. Thyroid function was classified as euthyroidism, hypothyroidism, and recurrent hyperthyroidism in 5, 34, and 3 patients, respectively. At 92 months of median follow-up, two patients had modest operation-associated symptoms: one with swallowing discomfort and another with paresthesia in the anterior chest wall at the time of discharge. However, both patients' symptoms disappeared within 36 months after surgery. Young women were highly satisfied, with an overall mean satisfaction rating of 9.3 points.

CONCLUSIONS

Although the endoscopic approach may be relatively contraindicated for large thyroid glands, endoscopic subtotal thyroidectomy via the breast approach is a safe, feasible procedure with excellent cosmetic benefits, and it may be the procedure of choice in carefully selected patients with Graves' disease.

Thyroid surgery in the tropics

In the tropics thyroid surgery is carried out either by general surgeons or ear, nose and throat surgeons and there are few places with a subspecialist endocrine or head and neck surgeon. The aim of this review is to determine the pattern of thyroid pathology, surgery and surgical outcomes in the tropics. A review of thyroid surgery in tropical regions was carried out based on published articles in English in Medline (1965-2004). The findings are also discussed in the light of the authors' own experience of thyroid disease and thyroid surgery in four continents. The pattern of thyroid pathology varies in the tropics, particularly in regions where endemic goitre is common. Endemic goitre usually regresses with iodine therapy. There is a rising incidence of thyroid autoimmune disease, particularly Graves' disease and Hashimoto's thyroiditis, probably related to an environmental immunological stimulus associated with development. Surgery is indicated for the same reasons as in the developed countries: thyrotoxicosis (more often in the absence of radioactive iodine therapy), solitary thyroid nodule and multinodular or malignant goitre. However, a preoperative cytological diagnosis will only be available in important centres where there is a pathologist. Malignancy appears more prevalent in nodules and goitres in the tropics than in the developed countries, perhaps because patients with malignancy are more likely to be referred to a surgeon. Nonetheless, the evidence suggests that thyroid surgery can be carried out safely with a minimum of complications even in remote mission hospitals with limited facilities for investigation. Standards can be set in terms of surgical outcomes; for example, mortality (0%), permanent recurrent laryngeal nerve (RLN) injury (<2%), re-exploration for haematoma(<2%), permanent hypocalcaemia (<5%) and wound infection (2.5%). The choice of operation depends on the local pathology and the likelihood of being able to obtain lifelong thyroxine. Total thyroidectomy should be avoided whenever possible if thyroxine supplies are unreliable. Advanced thyroid cancer presents a therapeutic challenge and some cases will be unresectable. The management options are limited by the resources available. Similar surgical outcomes should be able to be achieved no matter where the surgery is carried out.